主诉辨治法与微观辨证

“主诉辨治法”为“辨病脉证并治”、“辨证论治”的传承,又是“以证统病”,“专病论治”的创新,以抓住“主诉”,开展有序的问、望、闻、切四诊,结合新技术,来探讨病因、落实病位、阐明病机、分清病性、详悉病势、确定证名、依证立法、按法制方等分步骤论冶。     

金黄地鼠甲状旁腺主细胞的计算机三维重建

目的：建立连续超薄切片计算机三维重建方法并显示甲状旁腺主细胞的立体形态。方法：应用连续超薄切片和透射电镜技术、计算机图像处理技术，用“金子塔异或指数方法”实现连续超薄切片图像对位，体积显示算法实验三维重建。结果：在Ｓｕｎ工作站中形象地从各个角度揭示了甲状旁腺主细胞内高尔基体、线粒体、细胞膜等结构的立体形态和空间毗邻关系。结论：连续超薄切片图像计算机三维重建方法能直观地显示甲状旁腺主细胞各细胞器的立体形态。     

A System for Grouping Presenting Complaints: The Pediatric Emergency Reason for Visit Clusters

Objectives: To develop a set of chief complaint groupings for pediatric emergency department (ED) visits that is comprehensive, parsimonious, clinically sensible, and evidence‐based. Methods: Investigators derived candidate chief complaint clusters and ranked them a priori into three perceived severity categories. Pediatric visits were extracted from the National Hospital Ambulatory Medical Care Survey (NHAMCS); data for years 1998 and 2000 (n= 13,186) were used for derivation and data for year 1999 (n= 5,365) were used for validation. Visits were assigned to clusters based on the recorded complaints; clusters were combined to ensure adequate numbers for analysis (minimum n= 20), and the clusters were reviewed for clinical sensibility. Resource utilization was categorized in three levels: routine (examination only), ED treatment (tests or therapy in the ED but not admitted), and admission. Area under the receiver‐operating characteristic (ROC) curve (AUC) was used to demonstrate the discriminative ability of the clusters in predicting resource use. Results: There were 463 unique complaints in the derivation database; 95 (20%) had a single associated visit. Fifty‐two clusters were generated; only 2.4% of complaints were classified as other. The eight most common clusters encompassed 52% of the visits. The top five were fever (11%), extremity pain/injury, vomiting, cough, and trauma (unspecified). Complaint clusters were associated with actual resource utilization: for routine care, the AUC was 0.73 (0.74 in the validation set), and for admission, the AUC was 0.77 (0.74 in the validation set). Both resource utilization and triage classification increased with increased expert severity ranking (test for trend, p < 0.001). Conclusions: The proposed Pediatric Emergency Reason for Visit Cluster (PERC) system is a comprehensive yet parsimonious, clinically sensible means of categorizing pediatric ED complaints. The PERC system's association with measures of acuity and resource utilization makes it a potentially useful tool in epidemiologic and health services research.     

Memory self-appraisal and depressive symptoms in people at genetic risk for Alzheimer's disease.

OBJECTIVES: A previous study found that subjective memory loss in middle-aged and older persons is associated with the major genetic risk for Alzheimer's disease, the apolipoprotein E-4 (APOE-4) allele. No previous study has focused on subjective memory complaints and depressive symptoms in the same subject population at genetic risk for Alzheimer's disease. METHOD: Sixty-six persons (mean age = 64 years, range = 43 to 82 years) without major depression or dementia but with mild age-related memory complaints were rated for severity of depressive symptoms, using the Hamilton Depression Rating Scale, and assessed for the presence of the APOE-4 allele. Severity of subjective memory loss was assessed using the Memory Functioning Questionnaire, which measures four memory domains: frequency of forgetting, seriousness of forgetting, retrospective functioning, and mnemonics usage. RESULTS: Depressive symptoms were significantly associated with subjective memory loss in subjects without the APOE-4 allele, for retrospective functioning (perceived change in memory) and mnemonics usage, but not in APOE-4 carriers. The same significant associations were found when the analysis was limited to the 44 subjects in the mid-age range (55-74 years), wherein APOE-4 confers its greatest effects on risk for Alzheimer's disease. CONCLUSION: These results confirm that mild depressive symptoms are related to subjective memory loss, but for some forms of memory complaint, the relationship holds true only for people without the major known genetic risk for Alzheimer's disease.     

Evaluation of Heat-related Illness Surveillance Based on Chief Complaint Data from New Jersey Hospital Emergency Rooms

Objective

The purpose of this evaluation is to characterize the relationship between a patient’s initial hospital emergency room chief complaint potentially related to a heat-related illness (HRI) with final primary and secondary ICD-9 diagnoses.

Introduction

The NJ syndromic surveillance system, EpiCenter, developed an algorithm to quantify HRI visits using chief complaint data. While heat advisories are released by the National Weather Service, an effective HRI algorithm could provide real-time health impact information that could be used to provide supplemental warnings to the public during a prolonged heat wave.

Methods

Data on NJ hospital emergency room visits were evaluated using two data sources: 1) the EpiCenter syndromic surveillance system of emergency room visits; and 2) the Uniform Bill-Patient Summaries (UB) system containing diagnosis data on all hospital visits. Three years of data (2009–2011) were selected, for the time window of May 1 to September 30. The UB data used for matching with the EpiCenter data were limited to facilities participating in EpiCenter during the evaluation period. (EpiCenter facilities captured about 1/3 of all heat-related diagnoses in 2009, increasing to about 2/3 in 2011.) The ICD-9 codes of interest included 992.0–992.9 and external cause of injury codes E900.0 and E900.9. We evaluated the sensitivity and positive predictive value (PPV) of the EpiCenter algorithm in relation to the patients’ eventual diagnoses coded in the UB data.

Results

During the 15 months of data examined, there were a total of 871 people identified with HRI visits based on the EpiCenter algorithm. Over the same time period in the same emergency room facilities, there were a total of 2,146 people with a primary or secondary HRI diagnosis in UB. The algorithm for the EpiCenter’s HRI definition had a sensitivity of 16% (348/2,146) when any primary or secondary ICD or E-code matched; the PPV was 40% (348/871). When data during a major heat event (July 21–23, 2011) was examined separately, both sensitivity (23%) and PPV (59%) improved.Graph 1 presents the 2011 daily number of HRI visits from EpiCenter data and the subset of UB data from facilities also reporting to EpiCenter. The pattern in the EpiCenter data tracked with the UB data for HRI visits and correctly identified several major episodes in 2011.The major heat-related illness episode of July 2011 was selected to evaluate the non-matched EpiCenter and UB data. A total of 210 (95%) of the non-matched UB cases were able to be matched to EpiCenter chief complaint data. The EpiCenter information displayed a diverse range of general complaints, including syncope, dizziness, weakness, and headache. Similarly, non-matched EpiCenter data were compared to UB data to examine diagnoses, and 22 (48%) of the EpiCenter HRI cases were matched to UB diagnostic data. Diagnosis codes for these cases were for a variety of conditions classified under “general symptoms”; fluid balance disorders; asthma; diabetes; and unspecified hypertension.

Conclusions

The evaluation found that using chief complaint data to monitor HRI was relatively insensitive in comparison to the UB diagnosis codes, with a sensitivity of just over 16% for any UB HRI diagnosis. Sensitivity and PPV improved during a peak heat event.The evaluation of the non-matched data (both EpiCenter and UB) provided little guidance for modifying the algorithm. While expanding the algorithm to include complaints such as syncope, dizziness, or weakness may capture a few more HRI cases, it would also likely result in a greater number of false positive cases (i.e., higher background noise).Though not especially sensitive, EpiCenter data did identify all major episodes of HRI in 2011. The degree of correspondence indicates that the EpiCenter HRI algorithm provides a useful real-time gauge of the daily HRI trends.

Graph 1.

Open in a separate window2011 HRI visits identified by EpiCenter data and UB data subset for the same EpiCenter reporting facilities.     

设立住院总护士的可行性研究

目的 通过分析我国住院总护士实施现状及护理人员对住院总护士的认知情况,探讨设立住院总护士的可行性,为设立住院总护士提供依据.方法 (1)检索1990年1月-2010年6月有关住院总护士的文献,评价住院总护士的实施效果;(2)自行设计调查问卷,随机抽取5个科室305名注册护士进行调查,分析护士对设立住院总护士的支持度.结果 (1)经CNKI数据库共检索到9篇文献,有关住院总护士的研究始于2000年,目前仅有几所医院设立这一岗位.不同研究单位设立住院总护士的实施方法不同,取得的成效不一,各自在职责定位、岗前培训、配套管理制度等方面还存在很大的分歧及问题.(2)305名护士中不确定是否设立这一岗位的占8.9%,反对设立的占34.4%,支持设立的占56.7%;护士学历、职位较高者较支持设立住院总护士;支持设立住院总护士者中赞同周一至周五夜班、节假日24 h负责制的人数最多占32.1%;认为住院总护士的各职责中最重要的是应对突发事件和进行抢救,其次是安全管理和夜班查房.结论 已有的住院总护士工作模式还不够完善,在其岗位职责、工作时段的设定上还存在一些问题,护士对设立住院总护士可行性的认知存在较大差异,建议以岗位设置目的 为指导,参考护士对住院总护士职责的认知情况来设定岗位职责内容,对住院总护士的具体岗位职责、工作时段等进行进一步的探讨.     

Importance of role competencies for Chinese directors of nursing based on the Forces of Magnetism

spicer j.g., guo y., liu h., hirsch j., zhao h., ma w. & holzemer w . (2011) Journal of Nursing Management 19, 153–159
Importance of role competencies for Chinese directors of nursing based on the forces of magnetism Aim The aim of the present study was to survey directors of nursing (DONs) and chief operating officers (COOs) in the People’s Republic of China on the importance of DON role competencies based on the Forces of Magnetism. Background The present study describes part of an international collaborative effort to support the attainment of the Chinese Ministry of Health’s plan to strengthen and to increase the knowledge and skill levels of nurse administrators. Methods A random sample of 300 Chinese DONs and COOs was surveyed in the autumn of 2008. Results Compared with the COOs, the DONs were predominately female, had less graduate education and had more years of experience in their current role. Although the two groups perceived structural empowerment to be important, the DONs placed significantly greater importance on transformational leadership. Conclusion The Chinese DONs and COOs rated the role competencies based on the Forces of Magnetism to be important for DONs to be effective. Implications for nursing management The study’s findings support the transferability of the Forces of Magnetism to nursing management in hospitals internationally.     

Impaired memory consolidation during sleep in patients with functional memory disorder

Functional memory disorder (FMD) is characterized by mnestic and attentional deficits without symptoms of mild cognitive impairment or dementia. FMD usually develops in subjects with high psychosocial stress level and is classified to the somatoform disorders. We assessed memory performance (procedural mirror tracing task, declarative visual and verbal memory task) and other cognitive functions before and after one night of sleep in 12 FMD patients (mean age: 51.7 yrs, 7 females) and 12 healthy subjects matched for age, gender and IQ. Memory performance and other neurocognitive tasks did not differ between the groups at baseline. After one night of sleep, FMD patients showed an impairment of declarative memory consolidation compared to healthy subjects (visual task: p = 0.004; verbal task: p = 0.039). Spectral analysis of sleep-EEG indicated an increased cortical excitation in FMD. We hypothesize that a hyperarousal state in FMD might contribute to sleep disturbance implicating negative effects on declarative memory consolidation.     

戴明循环在医院医疗投诉管控中的应用

通过探讨戴明循环(PDCA循环)在医院医疗投诉管理中的应用,将PDCA循环引入医院医疗投诉管控体系,运用PDCA循环实施有效管理医疗投诉过程中的各项工作.自2006年起在医院通过引入PDCA循环,进行医疗投诉管控,到2009年底有效减少了医疗投诉的发生,并将医疗投诉在产生的初期就得到控制,减少了向医疗纠纷方向的转化,明显提高了医疗质量.应用PDCA循环可以有效控制医疗投诉发生,加强医疗安全,构建和谐医患环境.

Abstract：

A study of PDCA Cycle in managing hospital medical complaints may introduce such a cycle into the medical complaints control system of a hospital, effectively handling the medical complaints process. Since 2006 when the cycle was introduced into the hospital for medical complaints control, such complaints have been cut back significantly by the end of 2009. Furthermore, such complaints are under control from the start, and prevented from growing into medical disputes, effectively improving quality of care. Such a cycle can effectively avoid medical complaints, enhance medical safety, and build a harmonious doctor-patient relationship.